Dr. Scott Alexander MD

This patient had a face lift and brow lift leaving scars along her hairline. We previously transplanted hairline and upper temporals. At this time we transplanted and touched up temporals and side burns. We wanted to show the results of the trichophytic closure along the full length of marked area from previous surgery. The other photos are immediate post op pictures.

Here are some of my scar pictures if this helps. Let me know if you have more questions.

The number of grafts to accomplish your desired goal is the most important detail of the consultation. Once that is determined then you decide at the surgery how much tissue is needed to get the desired number of grafts. The length or width is as important as the elasticity of the patient and the ability to get those grafts. I really don't think any other details are important concerning the strip other than your ability of whether you can or can't get the number of grafts that you need. azn_guy I really think you are getting wrapped up into details that are not important. What's important is the ability of the doctor to draw and perform a natural hairline and to be able to give you the most density possible with the least amount of scaring. After all, your goal is a quality transplant and not how wide the strip was that was used to obtain the grafts.

If you have occasional breathing difficulties, this obviously should be checked out by your doctor to find out exactly what is causing this problem. As for hair growth, if you remain conscious, you are getting enough oxygen to keep your hair alive. This is not the cause of any hair loss that you may have.

This is an interesting question. As is everything in surgery, if sutures or staples are done poorly they both give bad results. Likewise if they are both done well, the results should be equal. The problem I see with staples is that most doctors do them not because they are better, but because they are easier and faster. I prefer using sutures because I am able to get the tissue to approximate perfectly every time which is the most important step in quality wound healing. One thing you do need to be careful with suturing is that you cannot pull the suture too tight or it can cause strangulation of hair follicles and actually decrease blood flow to the area. You can see why skill is always an important aspect in receiving good scars. If you leave the sutures in past 7-8 days, you have a good chance of causing "rail road tracks" or cross-hatching to form. In stapling it's hard to make them too tight because the tension is set automatically by the staple and can't be altered. It is very easy to have your incision over lap if the edges aren't aligned perfectly. These too must be removed within 7-8 days. Trychophytic closure would aide in giving optimal results in either of these closures. You just need to be sure that you have enough elasticity in the scalp to do it.

azn_guy_001, when talking about the human body and something that happens in nature it is impossible to use any of your mathmatical equations to figure out something that has so many variables as the amount of scalp you need in a strip to equal 3000 grafts. That is why dr's need to see patients in person to get a good idea of how much hair is available for transplant and how much scalp is needed to reach that goal. First, the hair in the back of the head is usually much more dense than the hair on the sides. Second, the scalp in the back usually has more elasticity than the sides. You need to figure in all of these variables to give an estimate on how much tissue you are going to need. On average, if a patient has very good density he is going to need a strip 1.5cm wide in the back tapering down to 1-1.25cm on the sides; and at least 30cm long. If the density is average in the back, the strip is going to need to be around 2cm wide in the back and 1.5 on the sides, being around the same length. If the density is average in the back, and you can only get 1.5cm wide in that area, you are going to have to take a strip at least 35cm in length to get that amount of grafts. Then if you want a trychophytic closure you have to figure in 1-2 rows of hair follicules that will be over lapped in the closer, thus needing even more elasticity. So you can see there is no easy calculation to figure how much hair you can recieve in any given surgery. It's always easy to say what you want, but it's not always what you can have. That is why it's best to go to your doctor for an in office personal consultation. Hope this helps.

It's been good to discuss hair loss options on here with all of you. I wanted to give you all another way to be in personal contact with me as well as to show you all the things we have going on at Biltmore Surgical. I have started a blog and would love for you all to take a look. Please become a follower on the blog (you will see the option on the right hand side) as well as leave a comment so I know who has stopped by. We will let you know when we post Before and After pictures, any new updates with our clinic, questions from all of you, things to do in Phoenix and much more. I hope that you stop by frequently as I will be updating often. Please take a look and let me know what you think! Dr Scott Alexander's Blog

Hello All, Since this patient has not responded back yet, I thought I would. This patient had 2814 Grafts in the frontal vertex. Yes, this patient is currently taking Propecia and has had great success. Thank you for all the kind words!!! Take Care, Dr. Scott Alexander

I agree totally with Dr. Hasson. It's been several years since most of the doctors maximum graft count was 2500 grafts and below. Today, mostly because of Hasson and Wong's large cases, those graft counts have been driven much higher. Because of the expertise that now exists, the time to do these cases is about the same as it used to be with the old smaller cases. The most important qualifications for large graft counts is definitely density and elasticity of the scalp. Some patients density might be so bad I would take the same amount of strip and end up with 1500 follicular units as I would to get 3000 follicular units. I think it is extremely important to do fewer cases with larger sessions because it causes less trauma to the donor area. I like to thank Hasson and Wong for pushing us to improve and grow in this area.

Good to read your experience CA323. We are all excited to see your results come in. Here are your pre-op and immediate post op pictures! PRE-OP SCAR FROM PREVIOUS SURGERY IMMEDIATE POST-OP

This is a very important question. The hairline is the most important part of the hair transplant and something that you are going to have to live with for the rest of your life. A good one makes the transplant undetectable or a bad one will cause you to want to wear a hat for the rest of your life. It is really amazing to me to think that hair transplant doctors in the past and continuing today use the semi-circle arc for a hairline. Just remember nothing in nature is a straight line and hairlines are never symmetrical. If you want a good test to see why I use a jagged line take your hand and pull back the hair on someone's hairline and look at the pattern that it makes. It always goes in and out. I base my hairlines on where it looks like the patient's hairline would have been if he hadn't of receded or gone bald. The most important thing is to tie it into existing hair; making it look like he hadn't lost anything. There are usually enough hairs on the head, although sometimes very few, to be able to tell where that hairline should be. Most of the doctors out there were taught through many geometric designs and measurements where to put the hairline. These always end up looking mechanical and unnatural. Every time they draw a straight line on the head, they have a tendency to follow that line. In fact, in our current journal, "Hair Transplant Forum International" on page 55, there is a contraption someone is trying to sell that uses a laser light to give you a straight lined semi-circle. If anyone knows of a doctor using this, please run the other direction! I attached a picture of it to this post. I cannot believe in this day and age that doctors are still wanting to draw lines like this.

Good to see you on here osidekid! Your results are looking great! When will you be able to come to AZ so we can take some updated pictures for you?

Sorry it has taken me so long to get back on this post. I just found it today. I wanted to clear up that I am an M.D. trained in General Surgery. TakingThePlunge, good to hear that you enjoyed your experience. I look forward to seeing your results progress.

With the tiny slits that we use for our recipient sites, they are sealed in the first 24 hours and as Dr. Feller states, nothing is going to penetrate the follicle to help it heal better. Grafcyte is used more for the scalp, but you have to understand that most of the peole using it are making larger slits. This is why they think it necessary to improve the healing of the scalp and to stop infection. At our clinic, we do not use anything at all post op. We allow our patients to shower the day after surgery, but we have them protect the grafted area from the pressure of the shower spray. We will allow them to rinse the area with cups of water after 2 days post op. As you can see from our results, the grafts heal just fine. You can also see from the comments that there are many ways to skin a cat. The most important thing is to not have an infection and to get good growth. Also you need to remember that as soon as that steril saline hits the scalp, it's no longer steril.

I agree, I wouldn't do anything less than 2500 grafts. If you want noticeable increase in thickness, you'll want to transplant the entire area in the front. When you look at the area through magnification, it will be easy to find places to stick the grafts. By using the custom cut blades it becomes very easy to go inbetween the existing hair to place grafts without injuring any of it. If anyone is trying to talk you into 1000-1500 grafts, I would run the other direction. I can tell by the photo and by the color of your hair in the front that it is already miniaturizing.

The key to a good result with your hair transplant is to see no visible scaring where the new hair is growing. In order to do this, you have to take the up most care in causing as little trauma to the area as possible. This can only be done with a custom cut blade, cut as small as possible to get the graft in safely. If you look at the shape of a follicle you will notice how well the chisel custom blade resembles the shape of the follicle. There is no reason to use a sharp needle because you have to penetrate too deep in order to get the graft to sit properly. This will cause undo trauma to the deep vascular bed. Also, the cut of the custom cut blade is very clean and straight allowing the edges to heal quickly and beautifully. Needles are round and beveled so not only do they dilate the area, but they can also tear the skin's surface microscopically. This can cause more unnecessary trauma. The other great attribute is that it's custom and cut during the surgery. If your follicles are big, you can cut your blade to the appropriate size. On the other hand, if your follicles are small, you can cut your blades smaller to help cause even less trauma to the scalp.

There is no reason to use Saline Spray on recently transplanted grafts. Saline doesn't cause any healing benefit at all. By keeping the area moist would only enhance the possibility of bacteria growing. The follicle itself is under the skin where it will stay moist with sterile body fluids. I would let the surface dry, form scabs, and let your body do its work. I think that Graftcyte is only necessary if you have large slits that need extra help for healing. If your slits are smaller than 1mm, you shouldn't need anything.

To get the optimal scar that is possible it is very important to have deep sutures placed with an absorbable type suture such as Vicryl, which takes the tension off the incision line for approximately six weeks. This will allow the incision to heal without being pulled upon preventing scar widening. If your doctor is using a non absorbable suture, make sure it is as non reactive as possible to your body. A monofilament, similar to fishing line or a nylon suture, is most commonly used. Personally in my practice I prefer to use Ethibond which is a non absorbable monofilament. The next important step is to remove the non absorbable suture as quickly as possible, usually within 5-7 days post surgery. Sometimes 5 days may be too early, and your doctor will be able to make that case by case judgment. The quicker it's removed, the less time the body will have to react to it. This is why the deep stitches are important because they will allow you to take the suture out quicker. If you leave the sutures in up to 14 days the skin will grow around the sutures making them painful to take out, much like Goldilocks' experience. It can also form railroad tracks and possibly killing hair along the suture line. The last step to a good closure would be using the trychophytic technique, which has been discussed a lot in the forums. Find out if your doctor uses these steps, if so you will have an excellent closure and result; if not, I would think about going to a different doctor. These steps should result in very little pain if any when you are getting your sutures removed.

I have sparingly used laser over the past year and half and agree with Dr. Feller that the scientific evidence is very sketchy and that our results have in no way met the expectations put forth by the laser companies. Until there is quality scientific data I do not believe that laser should be promoted as a medical treatment for hair loss.

We count our 3,4 and 5 hair grafts as multiple hair follicles. We do not separate them out, and we do not cut them up. We transplant them all in the same area, this would be in the deepest part of the transplant, or center so they do not look pluggy but blend in with the rest of the hair.

In response to the hair technician's statement from Dr. Keene, I would like to state that the comments posted were completely false. I do not split or trim hairs in order to achieve a greater number of hairs per square centimeter, I always believe it is best to leave the hair in its natural state, I wouldn't want to take a chance in harming the grafts. I can transplant 70 units per square centimeter when using one-hair units, 60 grafts per square centimeter when working with 2-hair units and 40 units per square centimeter with 3-hair units. This amount does depend on the patient, and their specific needs. I use a 0.7-millimeter blade for the one-hair grafts, 0.9 for the 2-hair grafts and 1.1 for the 3-hair grafts. I use these numbers as my baseline; if the hair is finer I go smaller and if it is coarser I go a little larger, but on average I use the baseline numbers. It is possible to transplant 60-80 grafts per square centimeter with a two-hair follicle. We do not perform this on everyone, it depends on the size of the area being transplanted, along with the amount of hair available to transplant. Obviously if the patient has lost a large amount of hair on top we are not going to be able to harvest enough hair to achieve this kind of density. This always has to be done on an individual basis after evaluating the total goal you are trying to achieve for that particular patient. What needs to be understood is that 80 grafts per square centimeter in a healthy scalp will grow. I also do not have a minimum dollar amount requirement; I will always do what is best for the patient. I also take care of any post-operative problems my patients have personally. In reference to the patent that came to your clinic, I find it a bit ridiculous to perform a surgery just to replace a few grafts that might have fallen out. This assessment cannot be made until the total outcome of the case is known and the growth is at its optimum.

Dr. Alexander prides himself in his undetectable, and extremely natural hair lines. The density he offers is as good as anyone in the US. Toby, MA Biltmore Surgical Hair Restoration Post op 5 months Post op 7 months 1yr post op 1yr post op

This pt received 2000 grafts in the crown area. Pre op photo Immediately post op 7 month post op Post op 1 yr Pt 2 also received 2000 grafts in the crown area after a previous procedure with a national hair transplant chain. Pre op photo 10 month post op

Scabbing is a product of the size of slit that was made at the time of transplant. If it was a large slit causing a lot of trauma you will have a larger scab that will take longer to heal. It you had tiny slits performed for example, by the custom cut blades which we use, your scabs will be smaller and will heal much faster. Therefore, you can not say that all scabs should be healed and gone in 10 days. Our scabs traditionally begin to fall off at 5 days and should be totally clean by 10 days. I have seen some scabs performed by other offices take up to 3 weeks to heal. What I suggest to my patients is to use an antibiotic ointment or aloe vera, as was suggested would be fine, to be placed on the scabs one hour before getting into the shower beginning on the 4th day to moisten them. This will make it much easier to wash them off with shampoo and water while in the shower. This is much more atraumatic then picking at them. By doing this those scabs that are ready to come off will wash off without leaving any scarring. Sometimes the hair will shed with the scab but the follicle will still be healthy underneath the scalp. This is another reason why using blades that are 1 mm or less is so important in a good hair transplant. Just remember the less trauma you cause the quicker wounds heal and you will be rewarded with a better result.

Somehair, You have been a nonsmoker long enough that you should not be affected. The scalp is very vascular and should be able to supply sufficient oxygen to heal your hair transplant without any problems of scarring or loss of grafts. The problem with scarring is going to be from the size of the blade that is used for making the slits. Be sure your physician uses something under 1 mm. The psoriasis is a different story. There is a good chance that the surgery could cause an exacerbation of your psoriasis. You need to see your doctor to see if you need any pre-medication to keep that from happening. The psoriasis will not cause any problems with the hair transplant.